The Development of a Nursing Documentation Model for Patients in Crisis, an Emergency Department of Bhumipol Adulyadej Hospital

Abstract

This research and development aimed to develop a nursing documentation model for patients in crisis, an Emergency Department. The samples comprised 1) 30 professional nurses. 2) 34 nursing documentation forms for critical patients before and after developing the nursing documentation. 3) 8 Key performants. The research tools include as follows: 1) focus group discussion, 2) the developed nursing documentation format for critically ill patients, 3) nursing audit checklist of documentation quality, and 4) questionnaire on perceived value of adopting the new nursing documentation model. The reliability values of the third and the fourth research tools were 0.98 and 0.95. Data were analyzed by using descriptive statistics, Mann-Whitney U test statistics, and Wilcoxon Signed Rank test.
The findings of the research were as follows: 1) Obstacles of nursing documentation revealed that (1) recording methods were not well aligned with the nursing process, charting was incorrect and discontinuous; 2) there were many recording forms and (3) there was no documentation manual. 2) The developed nursing documentation model consisted of (1) a structured format with the PIE system based on the nursing process with holistic approach, and (2) a documentation manual. Finally, the mean score of nursing documentation quality and professional nurses, perceived value of the documentation model were both higher after development of the model than before development to a statistically significant degree at the level of .05.